Institutional influences on the primary cesarean section rate in Utah, 1992 to 1995

A cohort study of maternal cardiometabolic risk factors and primary cesarean delivery in an integrated health system

BACKGROUND

Maternal cardiometabolic risk factors (i.e., hyperglycemia, pre-existing hypertension and high body mass index) impact fetal growth and risk of having a cesarean delivery. However, the independent and joint contribution of maternal cardiometabolic risk factors to primary cesarean section is unclear. We aimed to elucidate the degree to which maternal cardiometabolic risk factors contribute to primary cesarean deliveries and whether associations vary by infant size at birth in an integrated health system.

METHODS

A cohort study of 185,045 singleton livebirths from 2001 to 2010. Poisson regression with robust standard errors provided crude and adjusted relative risks (RR) and 95% confidence intervals (CIs) for cesarean delivery risk associated with risk factors. We then estimated the proportion of cesarean sections that could be prevented if the cardiometabolic risk factor in pregnant women were eliminated (the population-attributable risk [PAR]).

RESULTS

In a single multivariable model, maternal cardiometabolic risk factors were independently associated with cesarean delivery: RR (95% CI) abnormal glucose screening 1.04 (1.01-1.08); gestational diabetes 1.18 (1.11-1.18) and pre-existing diabetes 1.60 (1.49-1.71); pre-existing hypertension 1.16 (1.10-1.23); overweight 1.27 (1.24-1.30); obese class I 1.46 (1.42-1.51); obese class II 1.73 (1.67-1.80); and obese class III 1.97 (1.88-2.07); adjusting for established risk factors, medical facility and year. The associations between maternal cardiometabolic risk factors and primary cesarean delivery remained among infants with appropriate weights for gestational age. The PARs were 17.4% for overweight/obesity, 7.0% for maternal hyperglycemia, 2.0% for pre-existing hypertension and 20.5% for any cardiometabolic risk factor.

CONCLUSIONS

Maternal cardiometabolic risk factors were independently associated with risk of primary cesarean delivery, even among women delivering infants born at an appropriate size for gestational age. Effective strategies to increase the proportion of women entering pregnancy at an optimal weight with normal blood pressure and glucose before pregnancy could potentially eliminate up to 20% of cesarean deliveries.

Impact of Provider Competition under Global Budgeting on the Use of Cesarean Delivery

OBJECTIVE

To examine the impact of provider competition under global budgeting on the use of cesarean delivery in Taiwan.

DATA SOURCES/STUDY SETTING

(1) Quarterly inpatient claims data of all clinics and hospitals with birth-related expenses from 2000 to 2008; (2) file of health facilities' basic characteristics; and (3) regional quarterly point values (price conversion index) for clinics and hospitals, respectively, from the fourth quarter in 1999 to the third quarter in 2008, from the Statistics of the National Health Insurance Administration.

STUDY DESIGN

Panel data of quarterly facility-level cesarean delivery rates with provider characteristics, birth volumes, and regional point values are analyzed with the fractional response model to examine the effect of external price changes on provider behavior in birth delivery services.

PRINCIPAL FINDINGS

The decline in de facto prices of health services as a result of noncooperative competition under global budgeting is associated with an increase in cesarean delivery rates, with a high degree of response heterogeneity across different types of provider facilities.

CONCLUSIONS

While global budgeting is an effective cost containment tool, intensified financial pressures may lead to unintended consequences of compromised quality due to a shift in provider practice in pursuit of financial rewards.

Clinical perspective: creating an effective practice peer review process-a primer

Peer review serves as an important adjunct to other hospital quality and safety programs. Despite its importance, the available literature contains virtually no guidance regarding the structure and function of effective peer review committees. This Clinical Perspective provides a summary of the purposes, structure, and functioning of effective peer review committees. We also discuss important legal considerations that are a necessary component of such processes. This discussion includes useful templates for case selection and review. Proper committee structure, membership, work flow, and leadership as well as close cooperation with the hospital medical executive committee and legal representatives are essential to any effective peer review process. A thoughtful, fair, systematic, and organized approach to creating a peer review process will lead to confidence in the committee by providers, hospital leadership, and patients. If properly constructed, such committees may also assist in monitoring and enforcing compliance with departmental protocols, thus reducing harm and promoting high-quality practice.

Ambient Fine Particulate Matter, Nitrogen Dioxide, and Preterm Birth in New York City

BACKGROUND

Recent studies have suggested associations between air pollution and various birth outcomes, but the evidence for preterm birth is mixed.

OBJECTIVE

We aimed to assess the relationship between air pollution and preterm birth using 2008-2010 New York City (NYC) birth certificates linked to hospital records.

METHODS

We analyzed 258,294 singleton births with 22-42 completed weeks gestation to nonsmoking mothers. Exposures to ambient fine particles (PM2.5) and nitrogen dioxide (NO2) during the first, second, and cumulative third trimesters within 300 m of maternal address were estimated using data from the NYC Community Air Survey and regulatory monitors. We estimated the odds ratio (OR) of spontaneous preterm (gestation < 37 weeks) births for the first- and second-trimester exposures in a logistic mixed model, and the third-trimester cumulative exposures in a discrete time survival model, adjusting for maternal characteristics and delivery hospital. Spatial and temporal components of estimated exposures were also separately analyzed.

RESULTS

PM2.5 was not significantly associated with spontaneous preterm birth. NO2 in the second trimester was negatively associated with spontaneous preterm birth in the adjusted model (OR = 0.90; 95% CI: 0.83, 0.97 per 20 ppb). Neither pollutant was significantly associated with spontaneous preterm birth based on adjusted models of temporal exposures, whereas the spatial exposures showed significantly reduced odds ratios (OR = 0.80; 95% CI: 0.67, 0.96 per 10 μg/m3 PM2.5 and 0.88; 95% CI: 0.79, 0.98 per 20 ppb NO2). Without adjustment for hospital, these negative associations were stronger.

CONCLUSION

Neither PM2.5 nor NO2 was positively associated with spontaneous preterm delivery in NYC. Delivery hospital was an important spatial confounder.

CITATION

Johnson S, Bobb JF, Ito K, Savitz DA, Elston B, Shmool JL, Dominici F, Ross Z, Clougherty JE, Matte T. 2016. Ambient fine particulate matter, nitrogen dioxide, and preterm birth in New York City. Environ Health Perspect 124:1283-1290; http://dx.doi.org/10.1289/ehp.1510266.

Impact of non-clinical factors on primary cesarean deliveries

The patient characteristics that influence cesarean rates are well known. However, there are many non clinical factors that also influence cesarean rates. Understanding these non clinical factors and how they can be changed to improve care is an important part of obstetrics. Provider staffing patterns, the types of providers and how information can be used to effectively change practice patterns are explored in this article.

Labor and delivery nurse staffing as a cost-effective safety intervention

Numerous studies have identified a relationship between staffing levels and nurse-sensitive outcomes for medical and surgical patients, but little has been published on the impact of nurse-sensitive outcomes for the childbearing family and even less that examines the relationship of intrapartum staffing on adverse perinatal outcomes. Using a derivation of Donabedian's classic structure, process, and outcomes framework, a model is proposed, which would allow obstetrical primary care providers and administrators alike the opportunity to examine the influence of nurse staffing on adverse obstetrical events, including unanticipated cesarean birth in low-risk women or newborn intensive care unit admissions. It is recognized that hospitals carry a significant burden in the prevention of adverse outcomes that range from nurse staffing levels to the internal process and infrastructure of the hospital setting. Patient outcomes are a direct result not only of the patient's health status and characteristics (eg, socioeconomic position and ethnicity), but also of interactions with the healthcare delivery system. As such, the opportunity to examine hospital characteristics (structure and processes) that may be detrimental to safe patient outcomes is of paramount importance in providing optimal outcomes for childbearing women and their families.

Racial and ethnic disparities in the trends in primary cesarean delivery based on indications

OBJECTIVE

To examine trends in primary cesarean deliveries by indications and race/ethnicity.

STUDY DESIGN

We examined temporal trends in primary cesarean deliveries from 1991 through 2008 among singleton births (n = 540,953) in Kaiser Permanente Southern California hospitals using information from maternal hospitalizations and infant birth certificates. In addition, relative increases and 95% confidence intervals (CIs) were used to estimate differences in primary cesarean section rates by indication for the earliest (1991-1992) and most recent (2007-2008) periods. Racial/ethnic disparities in primary cesarean deliveries were examined by comparing the relative risks from multiple logistic regression models.

RESULTS

The rate of primary cesarean section among white, African American, Hispanic, and Asian/Pacific Islander women increased by 61.6%, 64.1%, 62.4%, and 70.2%, respectively, between 1991 and 2008. In comparison to the primary cesarean section rate for white women, the rate was 25% (95% confidence interval [CI], 22-29%) higher for African American women, 19% (95% CI, 16-23%) higher for Asian/Pacific Islander women, but 14% (95% CI, 13-16%) lower for Hispanic women. After adjustment for confounding factors, primary cesarean section rates remained significantly higher for African American women but lower for Hispanic women compared with white women. Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity.

CONCLUSION

We found that the overall primary cesarean section rate has increased over time. In addition, there is a wide variability in rate of indications for primary cesarean section by race/ethnicity.

Variation in the rates of operative delivery in the United States

OBJECTIVES

This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making.

STUDY DESIGN

We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004.

RESULTS

In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery.

CONCLUSION

Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Cesarean delivery rates in the United States. The 1990s

The increase in CS rates in the United States in the 1970s and 1980s and the gradual decrease in the 1990s have been the focus of considerable attention because of the increased maternal morbidity and cost associated with the procedure without apparent impact on infant mortality. Focused efforts to reduce CS have resulted in a modest decrease the rate of primary CS and a marked increase in VBAC. Considerable variation in CS rates exists among regions in the United States and among states within those regions. The states with the higher CS rates are clustered in the South and Northeast regions of the United States, whereas rates tend to be lower in the West and Midwest. This variation cannot be explained by standard demographic risk factors and is likely related to local culture and mode of practice. Patient case mix should also be taken into account when comparing CS rates. Accounting for differences risk may help highlight differences in mode of practice and thus identify opportunities for improvement. Several reports from hospitals and communities of education and peer review programs have resulted in a significant reduction in their CS rates without increasing perinatal or maternal morbidity and mortality. A common theme in these reports of successful strategies to decrease the CS rate safely is the importance of physician motivation to make a change.